I've been prescribed suboxone for a few years now. It has done wonders for my recovery. Recently, however, I have been getting pressure from the doctor. In two of my recent tests (not back-to-back), the suboxone metabolite norbuprenorphine was not present.

I want to preface the rest of this by saying that yes, I take it exactly as prescribed. I am on the film, not the tablet. I am only on 4mg/day. I take 2mg in the morning and 2mg mid-afternoon. The UAs I take are generally around 4pm, and I normally take my afternoon dose at around 3pm. The last time this happened, the next test showed it in my system again. However, this time the doctor made it clear that, while he personally believed I was compliant with all the rules of the program, he would have no choice but to discharge me if this kept happening. I told him I understood that with federal oversight he couldn't take any chances. I do sympathize with his view - he cannot put his other patients at risk for one that, at least according to the official metric, is non-compliant.

I am very dedicated to my recovery. I voluntarily attend 12-step meetings and see a psychiatrist monthly. I have not used in years. Both myself, and apparently the doctor, are at a total loss to explain this. The other baffling thing is that while buprenorphine itself does show up on the test, the metabolite DOESN'T. I'm really, really worried that I'm about to lose the central key to my recovery. I previously had to go to a methadone clinic daily, and it was very expensive and inconvenient (like almost 30 minute drive each way). I am terrified, confused and very, very worried. I was hoping I could find some information, or some theory, as to what could possibly cause this. So here's the only one I could think of:

I drink too much liquid, and the metabolite is being diluted below the detection threshold. I probably drink between 2-6 soda per day (I know, I know). I always make sure to drink about a full can before I go to the office because I know I'm going to have to take a UA. Could this possibly account for the missing metabolite? Or maybe something in my diet? I'm desperate for help. I know that I am not yet ready to transition off suboxone totally. It's my ultimate goal, but I'm not ready. I'm so scared I'm going to end up relapsing. Please, please if anyone has any information or ideas, I would be very grateful if you would share them.

You are very gracious about the situation; more than most people would be, and more than I would be. This is the problem with treating drug tests, rather than treating patients.

There are things that a doctor could do to assess compliance besides drug testing. There is no requirement that patients have specific results. Your doctor could simply document that he/she believes you are truthful, and has reasons to believe the test is not accurate. Doctors are afraid that a patient will die or do something harmful, and then later the chart will be reviewed, and people will ask 'why did you keep prescribing to this patient'? Doctors do NOT have to show the labs of patients to regulators and constantly prove things are OK. Heck, one solution for your doctor would be to just stop testing for the metabolite in your case. If you have buprenorphine in your bloodstream every time you are tested, then the metabolite is not that important.

Beyond all of that, I think that your hypothesis is accurate. Most test only need a tiny bit of urine; most people can eke out enough for the test at any moment... do you really need to drink the soda?

It is possible that the enzyme in your body that creates norbuprenorphine is less active than in other people. I believe CYP34A is the responsible cytochrome; look up CYP3a4 on wikipedia and you will see what activates it, and what inhibits it. The activity of that enzyme can really vary in different people, and maybe instead of turning bupe in to norbupe, you are metabolizing it through a different pathway-- or maybe excreting it unchanged in the urine or GI tract. Having a low activity of the enzyme chiefly involved in metabolism would explain, also, why you can get by on such a low dose.

However, this time the doctor made it clear that, while he personally believed I was compliant with all the rules of the program, he would have no choice but to discharge me if this kept happening. I told him I understood that with federal oversight he couldn't take any chances.

Complete BS. As Dr. J said there is no requirement to be testing for any metabolite. If he really has a concern you are not taking it and putting a piece of film in your urine then volunteer to dose at the clinic. If you actually are not taking it there should be some notable effect. If you are back on opiates (a poor premise, as that should have shown up on your screen). I suppose if you are bringing someone else's urine and dropping a bit of film in it that would cover you but again dosing at the clinic would very quickly show you were back on DOC when the precipitated withdrawals occur. If you got real drowsy I would wonder if you were clean but diverting your films.There is no requirements regarding urine testing, just recommendations and availability if indicated. I don't report results to the insurance companies, just that testing has been done on these dates, I have reviewed the drug data base, reviewed there counseling attendance and now would you pretty please authorize they continue to be approved for Suboxone.

Thanks for the feedback, it makes me feel a lot better. I'm going to try to cut down on the liquid intake, and take my whole (normally split-up) dose at once next time before the appointment. Not sure what else I can do, really. They said they had to judge by the urine results, which I understand as that is the criteria they use to judge EVERYONE.

However, it is a frustrating experience to finally be telling the truth about my commitment to recovery and have it suddenly questioned. I understand that many of us on this drug were drug-addicts, and trusting our word is incredibly difficult. The only reason I've been given the benefit of the doubt (or so I was told) is that I've never missed an appointment and never not complied with anything they've asked of me. I've tried to keep a positive attitude, because the last thing I want to do is antagonize the doctor.

Maybe the low dose I'm on combined with dilution is the reason for the issue. I'm thinking about purchasing a few disposable bupe tests to see if I can confirm that theory but recreating the conditions on the day in which the test turned up negative. If anyone else has any other theories as to what might cause this, please feel free to chime in.

I drink an enormous amount of diet Mountain Dew :/I drink more than u have described for urself. It's a huge weakness of mine..... diet Mountain Dew. It's never interfered with my drug screens, I have no idea if the lab inside my clinic checks for that metabolite though, I've never asked honestly because I've never had a problem. But hopefully pop doesn't negatively affect the results of anything. I mean, I switched to diet, that's as far as I'm willing to go

I'm sure it is very frustrating to be questioned when you are doing so well in your recovery. The two people who first answered your post are both doctors. I hope that their empathy toward your situation and their belief in you makes a difference to you, even though they are not the ones doing your testing. We are on your side and want to know how this ends up for you.

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